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MDS 3.0 Wound Staging- Understand Wound Care

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Published on Nov 22, 2011

More information at http://www.woundphysicians.com, http://understandwoundcare.com or 1-877-866-7123.
Vohra Wound Physicians: Healing Wounds, Saving Lives

MDS 3.0 Wound Staging:
This is a demonstration of a wound care physician explaining the proper staging of wounds using the MDS 3.0 staging convention. Japa Volchok, DO discusses the indications for each wound stage and explains why proper staging is important in documenting wounds. This demonstration is performed by a trained wound care physician for educational purposes only and should not be tried at home.

Today we will be discussing the correct staging of a pressure ulcer as it pertains to MDS 3.0. MDS 3.0 is a staging convention used for the resident assessment. In the staging under MDS 3.0, there are some differences when compared to the older MDS 2.0 staging system and the more commonly known National Pressure Ulcer Advisory Panel staging. The MDS 3.0 staging convention uses four stages and an additional stage for an unstageable wound. MDS 3.0 does not allow for reverse or back-staging of wounds.

The first stage is a stage one. This is an area of localized redness or erythema that is non-blanchable in intact skin.

A Stage 2 pressure ulcer presents as a shallow ulcer with an area of open epidermis. There is no evidence of slough. A Stage 2 may also present as an intact or a ruptured blister. The blister may contain serum fluid-filled or a bloody fluid-filled blister. These are both staged as a Stage 2. If the underlying tissue with a blister shows evidence of deep tissue injury, or there is significant surrounding deep tissue injury, this should be staged as an unstageable secondary to deep tissue injury or DTI.

A Stage 3 pressure ulcer involves full thickness tissue loss including the epidermis and the dermis. It extends into the subcutaneous tissue but does not extend below the depth of the subcutaneous tissue. It may include tunneling or undermining as well as slough or necrotic tissue.

A Stage 4 pressure ulcer involves full thickness tissue loss involving the epidermis, the dermis, the subcutaneous tissue and includes exposed muscle, fascia, bone or other underlying structures such as tendon. There may be undermining and tunneling. In addition, there may be areas of necrosis or eschar present in the wound bed.

Depending on the anatomic location on the body, the depth of the wound can vary dramatically. The subcutaneous tissue over an area such as the ankle and the lateral malleolus or on the hands can be fairly thin. An area such as the heel or the back can have significant subcutaneous tissue before you reach the level of muscle or fascia. The actual depth of the wound does not dictate the stage. Rather, the anatomic structures that are involved such as muscle, tendon or bone are what determines the stage of the wound. If the bed of this wound was obscured by necrotic tissue it would be staged as an unstageable. However, it is clear that there are muscle fibers present in the base of the wound as well as bone. This would then be categorized as a Stage 4 pressure ulcer.

The final category of staging under MDS 3.0 includes unstageable. There are several reasons that a wound may be unstageable. If there is suspected deep tissue injury, the wound should be staged as unstageable. This is because deep tissue injury often progresses to a much deeper extent than has originally appeared on the surface of the wound.

Other signs of DTI include color change, bogginess or tenderness.

Other reasons for staging a wound as unstageable include necrosis that covers the full extent of the wound or eschar that prevents visualization of the entire depth of the wound and identification of the anatomic structures.

Additionally, under MDS 3.0, there is a category unstageable secondary to a non-removable device. This would be appropriate for staging a wound that has been present under a cast that could not be removed or some other type of medical device that would not be normally removed. This does not include wounds that are covered by negative pressure. Unless the negative pressure device has explicitly been ordered not to be removed except by the licensed physician that ordered the device.

Under MDS 3.0, only pressure ulcers are staged with this convention. Pressure ulcers of a Stage 3 or 4 are measured and recorded in the MDS 3.0 resident assessment. In addition, diabetic foot ulcers are recorded under a separate category and are not staged using the aforementioned staging structure.

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